Clinical guidance for managing COVID-19

All nursing and midwifery staff are fundamental to informing the public and reassuring them about the COVID-19 outbreak.

This page provides RCN members across the health and social care workforce, including nursing support workers and students, with clinical information and key resources to support their understanding of and help them with management of COVID-19.

Background

In late December 2019 a new (novel) coronavirus was identified in China causing severe respiratory disease including pneumonia.

The virus causing the infection has been named - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) this is a new strain of coronavirus causing COVID-19.

Since 19 March COVID-19 is no longer categorised as a High Consequence Infections Disease (HCID) in the UK, see Public Health England for more information.

As a newly identified virus there is currently no human immunity to it and no vaccine is available to prevent infection. As a viral infection, antibiotics are not an effective treatment.

Coronavirus

Coronaviruses are a common family of viruses and one of the main causes of the common cold. In general, most people infected with COVID-19 will present with mild to moderate respiratory like symptoms, but those with underlying illness and co morbidity are more likely to develop serious illness (see the WHO information).

Other examples of Coronavirus include MERS Co-V and SARS both of which have prompted global collaboration to reduce spread between people and to protect healthcare workers. The evidence from these outbreaks is being used to inform the response to COVID-19. As the pandemic progresses, scientists and health care professionals are continuing to learn more about how coronavirus is transmitted and how best to protect health care workers and treat those affected.

Current situation

It is a fast-moving evolving situation and as with any new strain of virus, the guidance for healthcare workers and health and social care services is being developed and updated frequently. This reflects the need to take a view of the global situation as well as the situation across the UK. Alongside a growing understanding of the infection risk of this new virus; incubation time, infectiousness and severity of the infection.

All nursing and midwifery staff, including, nursing associates, and healthcare support workers, must familiarise themselves with their local policies on emergency planning, infection prevention and control. They should also keep up to date with national guidance issued by the UK governments and relevant UK Public Health agencies.

This information is updated regularly to reflect the changing situation. It is important that members look on the web sites and check the links to ensure they are looking at the most up to date information.

UK Coronavirus response

The exact response to the outbreak will reflect the nature, scale and location of infection as the situation develops and members are advised to look on the links to the guidance to make sure they are accessing the most up to date information.

Information for the public; including stay at home advice for people who are self-isolating, from the NHS

RCN position

The RCN is not planning to develop any specific clinical guidance relating to COVID-19.

The RCN are working with national UK agencies and other key stakeholders such (for example other Royal Colleges) to support preparedness and management of the current situation providing an RCN perspective based on our role as a Royal College and Trade Union.

The protection of healthcare workers, development and review of guidance and resilience of healthcare provision is our current key focus. Please refer back to the main RCN COVID-19 (coronavirus) resource.

Professional guidance

CPR position and NMC code

During the COVID-19 pandemic, some people will become critically ill and their clinical progress, or lack thereof, will prompt frequent review of their likelihood of benefitting from cardiopulmonary resuscitation (CPR). These reviews should be documented and decisions should be easily accessible to all staff (such as Advanced Directions, ReSPECT documents or equivalent). All healthcare establishments have policies in place around CPR and guidelines on attempting CPR. Registered nurses are reporting that local CPR policy differs from national guidance and there is concern that following local or national guidance could mean criticism either way and breach of the NMC Code.

Due to the pandemic, resource and manning constraints in the surge of critically ill coronavirus patients mean conflicting CPR guidance is circulating nationally. Current Resuscitation Council UK guidance maintains early CPR and defibrillation gives people the best chance of survival and reiterates that all conversations and decisions around CPR are individual to the person involved; a blanket approach to decisions on whether or not to resuscitate individuals in an emergency is not supported. The RCN, NMC and GMC are unanimous in the use of advance care plans being made with people and patients, and are explicit that decisions must be made on an individual basis.

The NMC has re-iterated that all registrants are to use their professional judgement to decide what action should be taken in the best interests of the person in their care. Standards in the Code must continue to be upheld as they are useful to support decision making.

The RCN view is that registered nurses (and Nursing Associates in England) should use their professional judgement to provide CPR or not, taking into consideration the individual needing CPR, the current situation and environment they are in and local policy. Provided the registrant they can justify their actions based on these judgements, they should not face criticism.

Critical care and emergency department nurses are likely to be looking after more acutely and critically unwell patients. Nurse to patient ratios may be much higher than usual and they may require support from colleagues from other specialties not necessarily related to emergency or critical care. Therefore, they may have to supervise non-emergency/critical care colleagues moved to support the care delivery to the critically ill patients in their departments.

Read information from the Royal College of Physicians (RCP) National Early Warning Score 2 (NEWS2) system which has been developed to improve detection and response to clinical deterioration in adult patients. The system has not specifically been designed for the COVID 19 outbreak but is a vital tool to support clinical judgement with the emergency situations.

Is Nasogastric Tube insertion an Aerosol Generating Procedure?

Currently, Public Health England do not view Nasogastric Tube (NG) placement as an Aerosol Generating Procedure (AGP). The RCN agree with The British Association for Parenteral and Enteral Nutrition (BAPEN) and the Association of UK Dieticians (BDA) that insertion of an NGT regularly induces a cough or sneeze in patients and that this could generate both droplets and aerosols within the range of 1-2 metres required for proximity to the patient during NGT insertion. We have respectfully asked PHE in an open letter to change its guidance to reflect the decisions of the professional bodies representing those who have to insert NGT/NJTs during the Covid-19 crisis.

Cancer

Cancer and Coronavirus (COVID19)

Guidance has been produced by the One Cancer Voice* charities in partnership with NHS England.

RCN: Remote consultations guidance under COVID-19 restrictions. This guidance has been developed to support nursing staff, including health visitors, midwives and nursing support workers, where they are being asked to see and/or treat patients via a telephone or video or other remote consultation process.

National Early Warning Score 2 (NEWS2)

Read information from the Royal College of Physicians (RCP) National Early Warning Score 2 (NEWS2) system which has been developed to improve detection and response to clinical deterioration in adult patients. The system has not specifically been designed for the COVID 19 outbreak but is a vital tool to support clinical judgement with the emergency situations.

Read information from the Royal College of Physicians (RCP) National Early Warning Score 2 (NEWS2) system which has been developed to improve detection and response to clinical deterioration in adult patients. The system has not specifically been designed for the COVID 19 outbreak but is a vital tool to support clinical judgement with the emergency situations.

Scottish Commission for Learning Disability: COVID-19 Guided Self-help Booklet Series. A series of guided self-help booklets developed to support people with mild to moderate learning/intellectual disabilities during the COVID-19 outbreak.

Surrey and Borders Partnership NHS Trust: Videos to support people with learning disabilities and families/ carers

Alongside European colleagues, the BFS (British Fertility Society), supported by the Human Fertilisation and embryology Authority (HFEA) have agreed to cease all fertility treatments. Those in progress will continue and services will maintain storage banks but new patients will not be taken on at this time, see here for further information.

Read information from the Royal College of Physicians (RCP) National Early Warning Score 2 (NEWS2) system which has been developed to improve detection and response to clinical deterioration in adult patients. The system has not specifically been designed for the COVID 19 outbreak but is a vital tool to support clinical judgement with the emergency situations.

Delivering clinical services in non-clinical areas in General Practice

The RCN recognise that at this time of unprecedented demands on primary care balancing the need to maintain social distancing, while continuing to maintain essential services such as child immunisation clinics has led General Practice to investigate alternative ways to maintain these services. It is recognised that in order to limit the spread of the virus and protect patients and staff it is necessary to reduce footfall and maintain social distancing as far as possible in clinical areas.

We are aware that many patients and the parents of young children are reluctant to attend clinics for childhood immunisations or blood tests due to fears around COVID-19. In order to address this, some general practice surgeries are offering patients services in practice care parks and, in some cases, have been administering vaccines in the client’s car. Other reports suggest temporary tents or gazebos being erected to serve as clinical areas for phlebotomy services for example.

Delivering services in this way requires a number of considerations. The potential risks identified include:

Delivering services in different ways is an increasing demand for services during the pandemic. This is to help ensure social distancing as far as possible and minimise footfall in clinical areas.

There are some key considerations staff need to consider as part of the risk assessment for delivering the services in this way. A risk assessment is the responsibility of your employer and needs to be regularly reviewed and updated.

Community Nursing advice

Community Nursing in all forms is pivotal to the nation’s health and social care. We have put together some useful UK guidance. However, it is important that the nursing team familiarise themselves with their local policies on emergency planning, infection prevention and control and national other guidance.

Dementia

People living with dementia may find changes in patterns of life difficult to manage. It is important to explain to people living with dementia why there are changes are occurring and what is being done to keep them safe. Writing reminders, reinforcing details at each visit and encouraging virtual community support will all be helpful.

Read information from the Royal College of Physicians (RCP) National Early Warning Score 2 (NEWS2) system which has been developed to improve detection and response to clinical deterioration in adult patients. The system has not specifically been designed for the COVID 19 outbreak but is a vital tool to support clinical judgement with the emergency situations.

Safeguarding

We need to be aware that people may experience considerable stress during this outbreak and be in closer contact with household members for longer periods of time, which may increase issues related to safeguarding.

With infants and young children spending more time indoors it is important that we all remind parents of potential hazards in the home, including hazards such as blind cords. There have been one or two deaths recently of young infants/children getting tied up in blind cords. Info can be found at CAPT and NHS advice for new parents.

Adults

Changes in patterns of day to day life may result increased safeguarding events as people spend longer periods of time together without access to recreational activities and other opportunities to socialise, Community nurses need to be aware that they may be an increase in abuse, harm or neglect and understand their role for both adults and any children that may be involved.

Many of the usual options for respite care, such as day centres and home support, may not be available during this COVID-19 outbreak. This is likely to increase the stresses placed on family carers. Additionally, people with high levels of need may be exposed to unscrupulous persons who may contact them offering services or financial advice which may result in abuse. We recognise that community nurses will often be the only people who are entering the homes of many adults with high level of care need and will demonstrate their usual vigilance to identify safeguarding concerns. It is important you are familiar with any different ways of working in your locality in order to protect people.

Domestic abuse and COVID-19

Ethical guidance / rationing health and care support

The novel coronavirus (COVID-19) outbreak will have major implications for health and care services in the UK, and for health and care staff. This briefing is to support members making difficult decisions during this challenging time.

Background

Health and social care staff are faced with difficult decisions every day. However, planning for and responding to COVID-19 will require nurses and members of the nursing team to make difficult decisions under new and exceptional pressures, with limited time, resources and information.

These decisions could relate to the care we provide, how we provide it and who we can provide it to and could have wider impacts on the delivery of our health and social care services.

RCN Position

Making these difficult decisions should be based on our professional judgement, in accordance with the law, relevant guidance and evidence, and statutory duties.

This resource is designed to direct RCN members to the relevant resources designed to support specific areas of care but also provide some overarching principles.

It is critical that our decisions are made with transparency and are free from unlawful discrimination and personal bias, commensurate with the spirit of the Human Rights Act 1998 and Equality provisions operating across the UK.

The right to life must be preserved wherever possible

The protected characteristics of a patient such as their age, ethnicity, gender, sexual orientation, should not influence our clinical decision making without a clear evidence base for doing so.

Decisions must be taken in consultation and discussion with the patient during this pandemic, wherever possible.

Health and care workers must be supported including with relevant and adequate guidance and resources, in order to provide the best possible care in the context of this emergency.

Guidance

Wherever possible decisions must be taken in consultation and discussion with the patient. If treatment is available (subject to resources), and there is a real prospect that the patient would benefit, then the treatment should be offered.

A patient with capacity should be given sufficient information to make a real choice of which available treatment, if any, to consent to. If the patient lacks capacity, then the clinician should decide which, if any, available treatment is in the best interests of the patient, but should normally consult with the patient’s family and carers, or an independent mental capacity advocate (if appropriate), before making this decision.

A record of the decision and the discussion should be made.

If a treatment is likely to be futile, or harmful, then it need not be offered. For example, if there is no real prospect that mechanical ventilation will benefit the patient, then it should not be offered. The clinician should explain to the patient why it would not be appropriate. Ultimately, the patient does not have the right to insist on a treatment that would not be beneficial.

With recognition of the increasing pressures and demand on staff and on the health and care system, it might become necessary to make challenging decisions about how to direct resources to where they are needed most, and to prioritise individual care needs.

The framework intends to serve as a guide for these types of decisions, and that consideration of any potential harm that might be suffered and the needs of all individuals are central to decision-making.

Palliative and End of Life Care

Due to coronavirus infection (COVID-19) there will be an increase in numbers of people with Palliative and end of life care needs. This will include those who have also become palliative during the pandemic with COVID-19 and also unrelated conditions and be impacted by changes to health and care services in this time of unprecedented demand. This briefing is to support members at a time of unprecedented numbers of deaths due to COVID-19.

Background

Palliative care is the care people receive when their treatment is no longer considered curative. The Palliative care philosophy promotes holistic care looking after all the domains in life that makes us individual and important to ourselves and those around us. It is recognised that for some people, curative interventions for COVID-19 may be inappropriate and/or ineffective and a palliative approach to care may be implemented.

Palliative and end of life care is delivered by a range of healthcare professionals across the health and social care workforce. Community nursing caseloads will have a large proportion of people who have palliative and end of life care needs, and this is likely to increase. Palliative may need to be given in settings which do not normally care for people at the end of life.

People with current palliative care needs may fall within the vulnerable group criteria and should they contract COVID-19 they may find that they decline more rapidly than would have been expected. Advance care planning is critical to ensuring that people who are or who may become palliative during this pandemic have opportunity to discuss their wishes.

Conversations with people who are approaching the end of their life are not always easy, but they are necessary. Opportunities to discuss Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) with the person or their advocate/family if they lack capacity,are important and should be initiated as early on within the illness as possible. Advance Care plans including advance directives to refuse treatment should be discussed and support put in place to complete, should the person decide that this is what is important to them.

Where a person lacks capacity then a decision in their best interests (a best interests decision implies a formal legal decision under MCA) should always be made supported by the people that know them the best. Or who have powers of attorney

As a result of COVID 19, life expectancy may be shorter than previously expected and people and their families should, as far as possible, be prepared for this. Sensitivity and kindness must prevail even in these challenging situations.

Hospices and specialist palliative care providers may change the way they are working during this pandemic.

Guidance

Dignity, respect and compassion must remain at the core of the delivery of end of life care.

People approaching the end of their lives should still be engaged in conversations about their treatment during this pandemic, wherever possible. This may form a part of advanced decision-making conversations. See section on DNACPRand advanced decision making

As far as reasonably possible, people’s cultural and religious beliefs should be explored and respected. However, as the pandemic increases, this may not always be possible.

Health and care workers in all relevant settings must be supported including with relevant and adequate guidance and resources, in order to provide the best possible end of life care in the context of this emergency.

Resources to support practice

Further protocols and guidance are currently being produced to support care of the dying in the community, and in mental health. This will be added to this resource as they become available.

Read information from the Royal College of Physicians (RCP) National Early Warning Score 2 (NEWS2) system which has been developed to improve detection and response to clinical deterioration in adult patients. The system has not specifically been designed for the COVID 19 outbreak but is a vital tool to support clinical judgement with the emergency situations.

Social care and care homes

Nursing teams work closely with many community and staff groups. Set out below are the links to guidance covering different sectors that may be helpful to you in managing day to day interaction with colleagues and will inform your own practice.

Care home providers should stop visits to residents from friends and family. Healthcare professionals and delivery couriers can still visit.

Read information from the Royal College of Physicians (RCP) National Early Warning Score 2 (NEWS2) system which has been developed to improve detection and response to clinical deterioration in adult patients. The system has not specifically been designed for the COVID 19 outbreak but is a vital tool to support clinical judgement with the emergency situations.